Reminiscence and Reflection: Life Review Therapy with An Elderly Patient

By Psycho Pharma on November 27, 2018

by Rachel Saks, Psy.D.

Assistant Professor of Psychology, Chestnut Hill College.

Maya Angelou once said, “There is no greater agony than bearing an untold story inside you.” This quote rings true as an essential aspect of human existence. Narratives are the way we organize experiences, convey memories, and share our truths. Much of psychotherapy is an act of storytelling. The patient delivers a narrative, and the therapist listens intently, clarifying details and motivations, confronting gaps and false statements, and interpreting subtext and thematic content. The teller selectively recounts events and describes characters with her audience in mind, unconsciously editing the story in response to transference feelings. Through our stories, we describe and define ourselves, with the hope that the narrative has some resonance and meaning. Nowhere is this more evident than in work with older adult clients. As a therapist working with elderly patients in nursing homes over the course of ten years, I came to realize the essential value of life stories told and received. In this way, time is distilled and cohesion may be restored or created. I believe that we all strive to be known by others, but it is through the telling of our stories that we come to know ourselves.

As described by Erikson (1980), the last stage of psychosocial development, ego integrity vs. despair, arises in response to the crisis of old age and impending death. Individuals seek to better understand their choices, relationships and acts, to develop a sense of their lives as cohesive and meaningful. Butler (1963), a contemporary of Erikson, explained that life review is a naturally occurring, universal process at this stage, wherein previously unexamined conflicts may be explored and resolved. Psychoanalytically-oriented therapy with older adults often focuses on the resolution of this task, and offers a rich opportunity for increased insight and the ongoing development of the self.

Butler identified three groups at risk for pathological responses to life review resulting in guilt, depression and anxiety. First are those who always look forward. These individuals habitually engage in defensive avoidance of examining the past. Second are those who have severely and consciously hurt others. These individuals struggle with legitimate and sometimes overwhelming guilt. And, third are those with narcissistic tendencies, for whom death may be seen as the ultimate insult. In my experience, and beyond Bultler’s three categories, I would add that those who have experienced significant trauma represent a fourth at risk group. Many older adults with whom I have worked have pointed themselves ever forward, thereby avoiding the task of mourning, or even acknowledging past trauma, only to find themselves overwhelmed at this later stage by past events they thought they had overcome.

This paper will examine life review therapy with “Isaiah,” a 93 year-old African American man seen in psychotherapy in a nursing home setting. I worked with Isaiah over the course of nine months, meeting weekly to engage in psychodynamic life review. Isaiah’s legitimate guilt and shame, triggered by the developmental press to look back at this life, may be understood as the primary cause of his severe depression. It was through our work together that he processed this guilt, came to understand the impact of individual and cultural trauma on his choices and identity, and ultimately restored some sense of integrity.

Isaiah arrived at the nursing home following hospitalization for a minor stroke. Prior to becoming ill, he had been living in an abandoned apartment with a friend. According to the social worker who referred him for treatment, they had been living with no heat or electricity, and barely any food. Though both the doctor and physical therapists had determined that Isaiah should be able to regain full functioning and return to the community with support from the local senior services organization, Isaiah had made little to no progress. He had gained no weight, and refused to get out of bed or participate in physical or occupational therapy. When I first met Isaiah, he barely made eye contact. He shrugged his shoulders and consented to work with me, but assured me that there was really no point. “It’s the bottom of the ninth,” he said. “Two outs. It’s time to pack up and leave the park.” Such a response is not unusual with many older adults. They have often been socialized to regard therapy as only for “crazy” people. It is also the case that African Americans, particularly from this generation, have learned that you do not share your personal business with therapists, particularly white ones. Yet there was something about the way in which he carried himself that alerted me to the fact that this resistance was about more than that. He seemed to feel that he wasn’t worth the time. Convincing him that he might find himself playing extra innings regardless of his plans, and he might want someone on this team, I began to lay the groundwork for our alliance.

Despite the severity of his depression, Isaiah presented with evident strengths. He was obviously intelligent, perceptive and able to make use of humor. I began by exploring with him as to the reasons that made him feel that he should not work on improving his health. He was, he explained, baffled as to why he should still be alive when so many “good” people had already died. I wondered with him about why he might not regard himself as good. He insisted that he was bad, and that “Some things just should not be forgiven.” Was it his fantasy that he should be punished, and was he inflicting that punishment on himself? With this hypothesis in mind I began to question him about his identity. How was it, I asked, that he came to be so bad? In response to this, he began the months long process of telling me his story.

Isaiah grew up in the South in the early part of the 20th century. The first son of a highly educated and prosperous black family, he held special status both in his family and in the larger African American community. This, of course, was in contrast to the general discrimination, exclusion and racism he experienced among Whites. He described an ever-present internal tension that resulted from confusion about these divergent roles. From an early age he recalled feeling angry with his mother for her assertions that they were somehow better than other people he knew. She chastised him for playing with children she felt were beneath him. He didn’t feel truly seen by her, or by his emotionally absent father. At school and in the neighborhood he projected confidence and strength, but worried inside that he was not at all what people imagined him to be. Adopting the defense of presenting a false façade, that he did not care what other people thought, he managed quite well, but failed to internalize a sense of his authentic self as loved and validated.

Isaiah did well in school, and enjoyed social success and the admiration of his peers. Delaying college, he played for a time as a catcher in an all African American minor league team. He was a natural leader on his team, and enjoyed the experience of brotherhood he felt. He fell in love, and married a local girl with what he felt to be high standing, who garnered approval from his parents and younger siblings. It was when he came back from serving in WWII that he became “bad,” he explained. He left his wife, became estranged from his family, and began a life of crime. He was eventually imprisoned, spending over twenty years in jail.

Isaiah fought in the military in the North African desert against General Rommel’s Army. He was a sniper. He described long, exhausting hours of waiting and worrying, broken up by tense frightening battles. He was considered an excellent sniper, talented at shooting and killing his targets. He was highly admired, and yet, he felt enormous dissonance and guilt about what he was doing. His leadership, along with his marksmanship offered him a potential career path, but he chose to leave the Army rather than rise in the ranks. He could not reconcile succeeding in an organization that denied his fellow African American soldiers the opportunity to integrate, to become officers, or to go to the officer’s club. He left the army and returned to a country that celebrated its victory in war, but did not laud, or in many cases even recognize, the contributions of black soldiers. For him there was no GI bill, no subsidized housing, no medals, and no parade.

Isaiah returned home a confused hero, unable to convey his complex emotions to his family. He didn’t recognize himself, and though he tried at first to re-enter his life, he felt unable to find his former ability to maintain a confident edifice. His relationships fell apart and he couldn’t hold down a job. He was angry and scared, and there was no place for him. He began to dabble in petty crime, and became connected with the local African American organized crime syndicate. And there, he found a place where his skills were respected, and where he felt like he fit in. He became a gangster. That, he explained, was how he became bad.

It was difficult for Isaiah to be frank in discussing the many things he did in the years that followed. Only as he began to trust the constancy of my commitment to him and my nonjudgmental acceptance of him, did he begin to share this part of his story. Isaiah was a leader. He had several nightclubs, ran rackets and had brothers in arms. He robbed banks. He was also “muscle,” and he committed murder. He insisted that I understand that he had done irredeemable harm. He asked me to imagine looking in a man’s eyes as he begged for his life and taking it anyway.

Yes, some things cannot and should not be forgiven, but they can be understood. This is the essence of life review. It is only by examining the full story that we can begin to see the full tragedy of it. I once had a professor in graduate school who said that the goal of psychoanalysis was not to be rid of our faults and burdens, but was, instead, to become the tragic hero of our own stories. In Isaiah, we see many disparate lives lived: That of a young and angry but successful and popular man, that of a skilled but conflicted sniper, that of a marginalized black soldier, that of a successful criminal, that of a long-time convict, and that of a poor, lonely and guilt-ridden older man. With this in mind, ego integration was an exceedingly difficult task, particularly under the specter of his justified guilt.

Who was I to him? As is always the case, the transference evolved over the course of the therapy. I was at times a friend, a confessor, a lost wife, and finally a much needed mother to him. It was clear from the beginning that he felt I should not like him. He projected my disapproval and judgment, and saw me as an unwilling recipient. At first distant, he eventually became warm and open. He would often say, as I walked into his room for a session, “Here she is, my ray of sunshine.”

There were a few key turning points in our relationship occurring in the context of my sharing my perspective on his life story. Seen from without, it was clear to me the immense role that trauma played in his life. Living in the era that he did, he had no language for trauma and no understanding of its impact. I was, over time, able to help him to develop some empathy for the troubled young man that returned from the war plagued by confusion, anger and self-loathing. I was able to help him to understand his drive to endlessly relive his days as a sniper. The ongoing toll of this trauma became evident during one session when an older black man walked by the door of his room with his hand in his pocket and Isaiah snapped up in alert. He was ever vigilant, still expecting to be “taken out,” by another killer.

It was also crucial to examine the role of racism in his marginalization, complicated by his identification with his mother, who in her own way may have contributed to the oppression of working class African Americans by looking down on them. While I could not draw on my own experiences as a privileged white woman born in the later part of the century, I was ever-curious in exploring this dimension of his experience, and drawing his attention to its impact. I have wondered since about his feelings towards me and my whiteness. I think it was my curiosity and persistence about trying to understand this aspect of his experience that may have allowed him to explore it with me. I have also wondered whether my own guilt about my privilege may have in some way mirrored some of the guilt he felt.

In terms of countertransference, I had a variety of feelings. This was, perhaps, the most moving course of therapy I have participated in to date. I felt concerned and protective, and also at times repelled by his past. I felt overwhelming sadness for him, and struggled with the power of his regret. It is always the case when working with older adults that we must confront our own fears of aging and dying, and also the stark possibility of finding ourselves at the end of life, filled with regret and unable to go back and make amends. There is also an element of fascination and voyeurism that can be a distraction as you find yourself drawn into another time and place, akin to watching a flashback scene in a movie, transported to a different time and place with full costume and dramatic music score. His story was not for me, but for him, and this was what I needed to remind myself when I found the fascination a distraction.

Relational therapists talk about the power of becoming progressively more honest in the presence of another person. Isaiah needed not only to be honest about the harm he had done, but also about the pain and isolation he had felt and feels still. Since he was a child, he had longed for someone to really see him, without judgment, and to accept him. I have found that no matter how old people become, when they are vulnerable and sick, they yearn to be held by a loving and protective mother. I think that Isaiah did not need punishment or absolution, so much as he needed to be mirrored and cared for and really seen.

When I do life review therapy with older adults, an extraordinary thing happens. I begin working with someone bent and wrinkled with age. As they tell their life story, I begin to see someone else emerge, or rather many other selves emerge. People come alive, their posture changes, their faces light up, and I am able to interact with the child, teenager, or adult they once were. As we travel through time, I get to meet these selves, and together we discover that all of them still live. This is integration, and it is remarkable.

It was only after Isaiah and I greeted and made peace with these former selves, that he was able to acknowledge other aspects of himself and find some hope and purpose. He was able to finally mourn the loss of his family and wife, the loss of years in prison, and the loss of the life he might have led. As he did this, his condition improved. He began to walk, to care for himself, and to put on weight. He remembered that though he had caused great harm, he had also done some good. After being released from prison he had worked for a time with a local organization for the homeless. “I did help some people,” he said. “Some people found a place to live because of me.” When the time came for his discharge, he felt he had a purpose. He would go to subsidized housing for seniors, and spend some time in the neighborhood talking to young guys. He wanted to pass along some wisdom and hopefully help them from making some of the mistakes he had made.

Many months later, Isaiah returned to the nursing home, this time after a much more severe stroke. These were to be his final days. He was weak, struggling to breathe, and nonverbal. Of course, I could not resume therapy with him, but I did go and sit with him. He held my hand, and looked in my eyes, and I like to think that all of the selves he had been looked back and saw me, seeing him in all of his truth. Each of us has a story to tell. As therapists, we have the unique honor of hearing those stories. Writing this for me has been a labor of love. Isaiah had a story to tell, and by passing it along I hope to keep some part of him alive.

References:

Butler, R. N. (1963). The life review: An interpretation of reminiscence in the aged.

Psychiatry, (26) 65-76.

Erikson, E. H. (1980). Identity and the life cycle. New York: W.W. Norton.

Hendricks, J. (1995). The meaning of reminiscence and life review. Amityville, NY: